AMPATH Care Program Innovations

AMPATH’s model developed in Kenya capitalizes on the inherent power of an academic health center to serve as a resource to its country’s ministry of health and public health sector. By “leading with care,” AMPATH’s integrated system of health service delivery has enabled the following key innovations:

AMPATH has enrolled over 200,000 people living with HIV and operates in over 300 clinical sites in western Kenya in partnership with the County health leadership teams. Through partnerships with the pharmaceutical industry, AMPATH also facilitates screening, control, and treatment services for cancer, cardiovascular diseases, pulmonary diseases, diabetes, high-risk pregnancies, and mental illness through emerging Centers of Excellence at Moi Teaching and Referral Hospital and affiliated hospitals and health centers.

Population-based care: A population-based approach is grounded in the hypothesis that early detection of at-risk individuals and asymptomatic conditions such as HIV, hypertension, diabetes, and cervical cancer holds the promise of a significant reduction in morbidity and mortality. At the same time, finding patients before they become symptomatic creates a cadre of patients more readily task-shifted to lower level providers. Within AMPATH’s system, door-to-door counselors were initially dispatched to find everyone with HIV. Over time, these same counselors began testing for other asymptomatic or unrecognized conditions like hypertension and diabetes.

Community Groups: AMPATH has leveraged the inherent sense of community in much of western Kenya to establish community-based groups consisting of 15-30 members. A broad range of common interests holds these groups together. Groups may share common medical conditions, such as pregnancy, HIV, or diabetes. Others are bound by financial incentives, such as cooperative farming ventures or shared saving accounts used for small loans to support income generation. Most groups have combinations of financial interests and shared medical concerns. Community groups are capable of much more than enhancing their own income security and health outcomes. They represent a more informed community voice capable of holding Ministry of Health care systems accountable while becoming an active partner in their own care. They represent a powerful force for changing quality of care and the health of their communities. Chamas and GISHE (Group Integrated Savings for Health and Empowerment) are two AMPATH models improving health and wealth for their members.

Income and Food Security: AMPATH began introducing a village-based savings and loan system into community groups several years ago. Groups are trained to save small amounts of money that are pooled together for loans to members of the group to begin small businesses, improve farm inputs, etc. Those who borrow pay back to the pooled account with an interest rate of approximately ten percent. Loan defaults are less than five percent and profits realized are divided annually among group members on the basis of the shares of the pool they own. Profit on the pooled savings exceeds 30 percent per year. Growth of the program is self-perpetuating. Farm groups consist of 20-30 small scale farmers committing their land for common ventures. Groups receive training from AMPATH agriculture staff on farming techniques, group dynamics, and marketing. Some groups have succeeded in signing large, competitive tenders and have subsequently built their own storage warehouses and purchased trucks and tractors. AMPATH farm groups now sell to World Food Program’s Purchase through Progress initiative. AMPATH farmers supply more than half of the initiative’s purchases in Kenya.

Maternal, Neonatal and Child Health (MNCH): Through USAID support and additional funding secured through Saving Lives at Birth, and Grand Challenges Canada, AMPATH has implemented novel approaches in maternal, neonatal, and child health in seven sites covering a population of 750,000 in western Kenya since 2010. These approaches are now being scaled-up to reach an entire catchment population of more than 1 million people. AMPATH also protects babies by blocking mother-to-child transmission of HIV and reducing the rate of transmission of HIV from these mothers to their children from 35 percent to less than 4 percent.

Non-communicable Chronic Diseases: AMPATH is among the first in sub-Saharan Africa to layer programs targeting non-communicable diseases onto the infrastructure originally created for HIV care. Comprehensive Care Centers for HIV are being transformed into Chronic Disease Centers utilizing the same providers and infrastructure. The program has adopted similar methodology, utilizing the same counselors engaged in door-to-door HIV testing. Targeted conditions include hypertension, diabetes, chronic lung disease (predominantly due to indoor air pollution), cancer (predominantly cervical and breast) and mental health disorders.

Revolving Fund Pharmacy: One of the unfortunate limitations in Ministry of Health primary care services is recurrent stock-out of essential medications. Aggressive scale up of health care services within these same facilities has little hope for success unless coupled with dependable access to essential medications at affordable prices. To solve this problem, AMPATH partnered with the Ministry of Health and local communities to launch Revolving Fund Pharmacies (RFPs). These pharmacies are stocked with quality generic drugs. If the Ministry of Health pharmacy is out of stock for a particular drug, the patient has the option of purchasing the drug from the nearby revolving fund pharmacy at a price only slightly higher than the cost at the Ministry of Health pharmacy. A waiver system is available so that no patient leaves the facility without their necessary medication. RFPs are being scaled to multiple sites and are now stocking essential supplies as well as drugs.

AMPATH Medical Record System (AMRS)/Clinical Decision Support System: OpenMRS, the platform for AMRS, was initially created and developed by medical informatics experts and scientists affiliated with Indiana University School of Medicine’s Regenstrief Institute, with input from informatics experts from around the world. OpenMRS has become one of the electronic record systems of choice in a number of African countries, including Kenya, and is active in over 40 countries worldwide. AMRS is foundational, playing a vital role in research, clinical program monitoring and evaluation, reporting, delivery of clinical services and clinical decision support. AMPATH is now poised to fully deploy the electronic medical record system throughout its model of population-based primary care. Key new features enable it to:

• Capture all clinical encounters into a single repository (e.g. in home or clinic; nutritionist or clinician)
• Transition to a paperless point-of-care capture of clinical encounters
• Assure point-of-care clinical decision support for providers to enhance best practices
• Assure Ministry of Health access and ownership of data at each major clinic

Advanced Practice Clinical Officer (APCO): These non-physician providers have demonstrated the capacity to manage high volume clinics with very complex patients in remote resource limited settings. In the HIV component of the AMPATH/MOH program, APCOs provide more than 95 percent of the care. Now, these same clinical officers are adding to their responsibilities the care of non-communicable chronic diseases. AMPATH has worked with the Government of Kenya and national certifying agencies to establish national curricula and more appropriate compensation packages and career advancement opportunities for them.

Referral Services: A small but important subset of primary care patients will need referral and specialized services. Faculty level partnerships in many clinical disciplines (ENT, plastic surgery, anesthesia, nephrology, cardiology, maternal fetal medicine, oncology, pathology, dermatology, orthopedics, child life, and many more) have led to enhancements in the quality of care. In early 2015, AMPATH opened the Chandaria Cancer and Chronic Diseases Centre, East Africa’s largest chronic disease referral facility designed to host Centers of Excellence for each of the targeted chronic diseases. These same Centers of Excellence have experience with mobile extensions of their expertise to the key district/county in AMPATH’s population-based model of primary care. AMPATH’s specialists at the Centers for Excellence will direct necessary improvements in care protocols, provide mentorship for primary care providers, and lead research efforts as a vital component of any health system.

Oncology: Over 15 years ago, a deliberate partnership of IU Simon Cancer Center and five other North American Institutions was formed through AMPATH to address the impending epidemic of cancer in sub-Saharan Africa, for which it was ill-equipped to manage. This effort has been building on the AMPATH platform of education, research and clinical care for the prevention and treatment of cancer in western Kenya. From a few hundred patients seen annually, the AMPATH Oncology program now sees over 800 patients a month. Through joint philanthropy, a $5.5M Chandaria Cancer and Chronic Disease Center was created and has the capacity to treat with chemotherapy and radiation therapy. This is the first such facility serving the public sector in a catchment area of 20 million. Other accomplishments to date include:

• Establishment of a telehealth infrastructure for Moi Hospital. This same system is supporting virtual meetings for clinical and community education and tumor boards.
• The countries first formal training programs have been established for Gynecologic Oncology and Pediatric Oncology. Medical Oncology is expected to be approved as a formal program by Moi University in 2022.
• Dealing with the leading causes of cancer in sub-Saharan Africa, over 135,000 women have been prospectively screened for breast and cervical cancers.